Rose State College Dental Hygiene Application Procedure Fall 2013

11/08/12 R:\Dental\DH Application\Application Form\DH Application 2013.part 1.docx 1
ROSE STATE COLLEGE
DENTAL HYGIENE PROGRAM
APPLICATION PROCEDURE
FALL 2013 Entry
CLASS OF 2015
The following steps must be followed before an application can be considered complete. All materials must be on file in the Dental Hygiene Program office by February 1, 2013. Applications will only be accepted if turned in by 5:00 p.m. on February 1, 2013 or postmarked February 1, 2013. Any documentation submitted after the application deadline will not be considered in the computation of candidates' points. The signature of the applicant is required in several areas of the application. The application will not be considered complete unless all documents have appropriate signatures. All application information and documentation will become part of the applicant file and will not be returned to the applicant.
1. Complete the application for admission to the Dental Hygiene Program.
2. Forward official transcripts from ALL colleges and universities attended. This is your responsibility. Copies are acceptable if Rose State College Admissions Office has official transcripts on file. However, it is the responsibility of the applicant that ALL transcripts or copies are on file with the Dental Hygiene Program. You may choose to personally deliver them to the Dental Hygiene Program office. A Rose State College advisement sheet is acceptable for completed RSC courses. Final fall semester 2012 grades must be submitted before the deadline. Any degree awarded must be posted on a transcript or verified by a copy of the diploma.
3. Complete the form indicating planned spring and summer 2013 enrollment information. If you are not enrolled in any spring 2013 course work, please indicate on the enrollment form, sign and return the form with the application. CHEM 1124, Introductory Organic/Biochemistry should be completed by the end of spring semester 2013.
4. ACT scores are required. Submit ACT Scores. It is permissible to have retaken the ACT examination. A copy of the RSC advisement sheet is acceptable documentation if the current scores are listed. Residual scores are accepted. ACT scores must be within three (3) years or not older than spring 2010.
5. COMPASS reading, writing, and math exam scores are required for program application. These are given at Rose State College daily in Student Services building, Room 210. Please see page 3 for additional information and take this information with you when you take the examinations. You must turn in your score sheet or a copy of the results with your completed application. A RSC advisement printout is acceptable documentation. COMPASS scores from other institutions are acceptable if printout submitted includes institutional information. COMPASS scores must be within three (3) years or not older than spring 2010.
6. Employment or observation, other than as a patient, in a dental office is required. This is usually a strong deciding factor in the decision to seek a career in dental hygiene. Additional points will be added to your application depending on the length of your employment or if you spent the equivalent of one week (32-40 hours) observing in a dental office. If observation is less than 32 hours no points will be awarded. To receive this credit, complete the Dental Office Experience form on page 7. Blank form may be duplicated for verification by more than one dentist. No points or credit will be awarded unless form is signed by the dentist and the applicant, and submitted before application deadline.
11/08/12 R:\Dental\DH Application\Application Form\DH Application 2013.part 1.docx 2
7. If you have worked as a dental assistant and have current expanded duty certificates from the Oklahoma Board of Dentistry, points will be added to your application. If you are currently a Dental Assisting National Board, Certified Dental Assistant (CDA) one point will be earned. To receive credit, provide copies of the current (2012-2013) certificates. These documents must be turned in with your application.
8. Complete Application Point Worksheet and submit with application. Documents verifying worksheet entries must be submitted: transcripts; test scores; diploma or certificate verification.
9. If you have made application to the Dental Hygiene Program within three years, please indicate on application. Any application materials you wish to transfer from a previous application can be transferred to your current application if requested in writing. We must have a new application for admission and current transcripts reflecting recent coursework. It is the responsibility of the applicant to provide all updated requested materials for the current application period.
10. Letters indicating your application status will be sent to you at the address on your application. You should receive this letter during the first week in March. Instructions for scheduling an interview will be stated in the letter. All interviews will be scheduled in March.
11. All steps outlined above must be completed and all material submitted to the Dental Hygiene Program office by 5:00 p.m. on February 1, 2013. Personal interviews are one of the final steps in the application procedure.
Send ALL materials to: Dental Hygiene Program
Rose State College
6420 Southeast 15th
Midwest City, Oklahoma 73110
Telephone: (405) 733-7337
ADDITIONAL INFORMATION:
Failure to designate Dental Hygiene Program as a part of the address on the envelope may result in delay or loss of your material. It is the applicant’s responsibility to see that their application folder is complete. All application information and documentation will become part of the applicant file and will not be returned to the applicant.
The highest ACT composite score, course grade, and COMPASS scores will be utilized in the evaluation of the Dental Hygiene Program applicant. Letters of recommendation are not required for application to the Rose State College Dental Hygiene Program. If letters are submitted they are not utilized in the selection process.
The opportunity to interview is based on criteria and points earned including required course GPA, ACT composite score, COMPASS scores, number of required science courses completed, experience and education achievements. Education achievements include degrees posted on transcripts, current DANB certificates, and current Oklahoma Board of Dentistry certificates. Interview invitations and class selection are based on total points earned.
The signature of the applicant is required in several areas of the application. The application will not be considered complete unless all documents have appropriate signatures.
11/08/12 R:\Dental\DH Application\Application Form\DH Application 2013.part 1.docx 3
COMPASS TEST
TESTING REFERRALS
You must see a counselor in Student Development, SSB, Room 100 for a testing slip.
TESTING POLICY
You may test twice during each enrollment period. The first day of Spring Enrollment in November begins one enrollment period and the Summer/Fall combined enrollment period in April begins the second enrollment period.
TIPS FOR TAKING THE TEST
 Be well rested before you test. If you are hungry, eat something before you test.
 If you have children with you, return when you have a sitter.
 If you wear glasses or contacts, be sure to have them with you.
 Try and relax (take a deep breath).
 Read the directions carefully. This is very important.
 Make use of the practice items provided by COMPASS. See the RSC website information below.
 Although the test is not timed, give yourself at least an hour and a half (preferably two hours) to complete the entire battery of tests before the Testing Center closes.
 Do your best. The test scores will be used for Dental Hygiene Program admission.
TESTING HOURS
Monday - Tuesday 8:00 am - 8:00 pm
Wednesday – Thursday 8:00 am - 6:00 pm
Friday 8:00 am - 5:00 pm
READING TEST TIPS
 After you answer all questions about a passage, you will be able to change your answers. You must answer all the questions about a passage before you can go back and make changes.
 Each test has a built-in practice session to familiarize you with the kinds of questions that you will encounter.
WRITING TEST-ESSAY TIPS
 Remember that while you are correcting an essay, you can change any part of the essay as many times as you like. Be sure all necessary corrections have been made before clicking “go on”.
MATH TEST TIPS
 Use of non-graphing calculators is allowed. You will also be able to use scratch paper and pencil. You will obtain these materials from the testing personnel.
 You will not be allowed to return to previous questions in order to change your answers. You must answer each question presented to you. You will not be penalized for guessing.
REMEMBER, you can always get extra help by pressing the “Help” key.
* Study guides for the COMPASS test are available at Student Services or the Testing Center. Rose State College COMPASS prep web page is located at http://www.rose.edu/compass-test-study-guide. Follow the links to the individual test study guides. 11/13/12 R:\Dental\DH Application\Application Form\DH Application 2013.part 2.docx 1
ROSE STATE COLLEGE
HEALTH SCIENCES DIVISION
6420 S. E. 15TH STREET
MIDWEST CITY, OKLAHOMA 73110
(405) 733-7359
APPLICATION FOR ADMISSION TO:
Dental Assisting: Nursing Science:
Certificate Beginning Track
Associate Program Career Ladder Track
Dental Hygiene Phlebotomy
Clinical Laboratory Technology Radiologic Technology
Health Information Technology Respiratory Therapist
Health Information Coding Specialist Certificate
NAME
(last) (first) (middle) (maiden)
RSC STUDENT I.D. # and /SOCIAL SECURITY #
EMAIL ADDRESS
HOME PHONE CELL PHONE #
ADDRESS
(number & street) (city) (state) (zip)
PERMANENT ADDRESS
(number & street) (city) (state) (zip)
EMPLOYER WORK #_______________JOB TITLE:
ADDRESS
(number & street) (city) (state) (zip)
PERSON TO CONTACT IF WE ARE UNABLE TO REACH YOU OR IN CASE OF EMERGENCY NOTIFY:
NAME PHONE
ADDRESS:
(number & street) (city) (state) (zip)
RELATIONSHIP:
HOW DID YOU LEARN OF THE ROSE STATE COLLEGE DENTAL HYGIENE PROGRAM?
SOURCE: INDIVIDUAL’S NAME: 11/13/12 R:\Dental\DH Application\Application Form\DH Application 2013.part 2.docx 2
Have you applied to the Rose State College Dental Hygiene Program before? (yes) (no)
If so, year year year
HIGH SCHOOL GRADUATE OR GED
(last high school attended) (year) (year)
(city) (state)
Have you participated in the ACT (yes) (no); if so, year year year
List all colleges or universities attended since leaving high school. All college transcripts must be on file in the Dental Hygiene Program office by the deadline.
NAME OF INSTITUTION CITY/STATE ATTENDANCE DATES MONTH/YEAR CREDIT HOURS EARNED DEGREES AWARDED
N O T I C E
NOTIFY THE PROGRAM DIRECTOR SHOULD ANY OF THE FOLLOWING SITUATIONS RELATE TO YOU:
> CONVICTED OF A FELONY OR HAVE FELONY CHARGES PENDING;
> COURT COMMITTED FOR MENTAL INCOMPETENCY;
> HABITUALLY INDULGED IN OR ADDICTED TO DRUGS OR ALCOHOL; OR
> CONVICTED OF FELONY OR ILLEGAL PRACTICE OF DENTISTRY.
THESE CONDITIONS MAY AFFECT YOUR ELIGIBILITY FOR LICENSURE, REGISTRY OR CERTIFICATION CREDENTIALS AND CONSEQUENTLY MAY HAVE A BEARING ON EMPLOYABILITY. ALL INFORMATION WILL BE HELD CONFIDENTIAL.
I affirm that the information, which I have provided for this application, is complete and accurate. I understand that my application will not be considered unless all necessary official transcripts have been submitted by the deadline and the application procedures completed.
SIGNATURE DATE 11/13/12 R:\Dental\DH Application\Application Form\DH Application 2013.part 2.docx 3
Spring 2013
I am enrolled in the following classes for the spring semester:
Course # Credit Hours Course Name College
Summer 2013
I plan to enroll in the following classes for the summer semester:
Course # Credit Hours Course Name College
I am not enrolled in any courses for the spring semester, 2013.
I do not plan to enroll in any courses for the summer semester, 2013.
Applicant's Signature Date
SPRING/SUMMER 2013 ENROLLMENT 11/13/12 R:\Dental\DH Application\Application Form\DH Application 2013.part 2.docx 4
The following minimal physical and mental qualifications are necessary to be considered for admission into and progression through the Rose State College Dental Hygiene Program:
1. The ability to move around in patient operatory area, laboratory and other work areas.
2. Visual acuity sufficient to observe and assess patient behavior, instrument and assess intra and extra orally,
and accurately operate equipment.
3. Auditory acuity sufficient to hear instructions, requests, and monitor equipment.
4. The motor ability necessary to manipulate instruments and equipment and to utilize palpation in patient
assessment.
5. The ability to speak, write, comprehend, and communicate the English language proficiently.
6. The ability to communicate in a professional manner and establish rapport with patients, peers, colleagues, and Program staff and personnel.
7. The ability to think critically and use problem-solving skills.
8. The ability to resolve conflicts appropriately and function effectively in stressful situations.
Rose State College will provide reasonable accommodations to persons with disabilities in order for students to have access to educational programs and services. Students with disabilities requiring accommodations should make the initial request for accommodation to the Counselor for Students with Disabilities. See Rose State College Student Handbook for further details.
STATEMENT OF ACKNOWLEDGMENT
I understand that I must be able to meet the above physical and mental qualifications independently or with reasonable accommodation. I understand that I am responsible for communicating requests for accommodation to the Counselor for Students with Disabilities.
I affirm that the application information, which I have provided in this application, is complete and accurate. In addition I affirm that the Experience/Observation form in accurate and is a truthful statement of my experience and/or observation. I understand that my application will not be considered unless all necessary documentation has been submitted and the application procedures completed by the published deadline. In addition, I understand that all applications and documentation will become part of the applicant file and will not be returned to me as the applicant.
SIGNATURE DATE
PHYSICAL AND MENTAL QUALIFICATIONS 11/13/12 R:\Dental\DH Application\Application Form\DH Application 2013.part 2.docx 5
DENTAL HYGIENE APPLICATION ACADEMIC WORKSHEET
ROSE STATE COLLEGE
FALL 2013 Entry
CLASS OF 2015
APPLICANT NAME_____________________ __SID# DATE____________
Complete worksheet and enter only information requested in blank spaces and submit with application.
Verification of this worksheet will be completed by Dental Hygiene Program personnel.
I. GRADE POINT AVERAGE GENERAL EDUCATION (25 POINTS POSSIBLE)
COURSE
COURSE # and NAME
GRADE
SEM & YEAR
COLLEGE
English Comp I
English Comp II
Speech
U.S. History
Amer Fed. Govt.
Intro Sociology
Intro Psychology
Nurtrition
Grade Value GPA Point Range
A=4 3.7- 4.00= 25
B=3 3.5-3.69 = 20
C=2 3.0-3.49 = 15
D or F =0 2.5-2.99 = 10
2.0-2.49 = 5
II. GRADE POINT AVERAGE SCIENCE EDUCATION (20 POINTS POSSIBLE)
COURSE # and NAME
GRADE
SEM & YEAR
COLLEGE
Intro Chemistry
Intro Bio/Org Chem
Microbiology
Human Anatomy
Human Phys.
Grade Value GPA Point Range
A=4 3.7-4.00 = 20
B=3 3.5-3.69 = 17
C=2 3.0-3.49 = 15
D or F =0 2.5-2.99 = 10
2.0-2.49 = 5
III. REQUIRED SCIENCE COURSES COMPLETED (5 POINTS POSSIBLE)
Check those completed with a grade of “C” or better. One point is awarded for each course completed.
Introductory Chemistry yes no
Intro Org/Bio Chem yes no
Microbiology yes no
Human Anatomy yes no
Human Physiology yes no 11/13/12 R:\Dental\DH Application\Application Form\DH Application 2013.part 2.docx 6
IV. ACT COMPOSITE SCORE (15 POINTS POSSIBLE)
Score_______ Year_______ Location
Point Range
33-36=15 points
30-32=13 points
27-29=11 points
24-26= 9 points
21-23= 7 points
19-20= 5 points
16-18= 3 points
0-15= 0 points
V. COMPASS SCORES (15 POINTS POSSIBLE)
Writing Skills Score
Scores Points
0 - 75 0 Date
76-80 1
81-85 2
86-90 3
91-95 4
96-100 5
Pre-Algebra/Numerical Skills Score
Scores Points
0-60 0 Date
61-70 2
71-80 3
81-90 4
91-100 5
Reading Score
Scores Points
0-80 0 Date
81-84 1
85-88 2
89-92 3
93-96 4
97-100 5
VI. EDUCATIONAL EXPERIENCES (8 POINTS POSSIBLE)
Higher Education Degrees Received (2 to 3 points):
Type of Degree Subject Date College
Total college credit hours earned:
Board of Dentistry Dental Assisting
Certificates:
 Radiation Safety (1 point) Yes_____ No _____
 Assisting with Nitrous Oxide (1 point) Yes_____ No _____
 Coronal Polishing/Fluoride Application (1 point) Yes_____ No _____
 Pit and Fissure Sealant Placement (1 point) Yes_____ No _____
Dental Assisting National Board Credential, CDA (1 point): Yes_____ No _____ 11/13/12 R:\Dental\DH Application\Application Form\DH Application 2013.part 2.docx 7
VII. MISCELLANEOUS INFORMATION
I have previously applied to the Dental Hygiene Program: Yes_____ No_____
If yes, what year(s) __________, ___________, _________.
I have attended a Dental Hygiene Program Information Session:
Yes_____ No_____
I have attended a Dental Hygiene Program Applicant Workshop:
Yes _____No_____
I have worked as a chairside dental assistant:
Full time: Yes_____ No_____
More than one year
Less than one year
OR
Part time: Yes_____ No_____
More than one year
Less than one year
I have worked the front office in a dental office:
Full time: Yes_____ No_____
More than one year
Less than one year
OR
Part time: Yes _____ No_____
More than one year
Less than one year
I have observed in a dental office or dental offices
32+ hours less than 32 hours
NA due to work experience
I affirm that the information on the Applicant Worksheet is accurate and complete to the best of my ability.
________________________________ _________________________
Signature Date ROSE STATE COLLEGE DENTAL HYGIENE PROGRAM
Dental Office Experience/Observation Form
Instruction to applicant: Attach this completed form to your Dental Hygiene Program application and submit by application deadline, February 1, 2013. Copies of this form may be made to list additional offices. TO BE COMPLETED BY THE APPLICANT:
Applicant’s Name: SID #
Dentist: Dental Office Name:
Address:
Street City Zip Code
Dental Hygienist:
Check One:
Type of Practice: General OR Specialty (identify)
I was employed by: OR I observed:
Dentist: Dentist:
Dental Hygienist:
Applicant Signature Date TO BE COMPLETED BY THE DENTIST:
I certify that the applicant named above worked or observed in this office for the period of time stated. While in the office, he/she was exposed to the role of each member of the office dental health team.
Validation Signature:
Dentist Date
Form must be signed by the DENTIST for credit to be awarded.
EMPLOYMENT
Check One:
OR OBSERVATION
I was employed part time in this dental office
I was employed full time in this dental office
I am employed part time in this dental office
I am employed full time in this dental office
Dates (months and years) of employment at this office:
My primary responsibilities:
(Check those that apply)
Front Office
DDS Chairside Assisting
RDH Chairside Assisting
Other (specify):
I observed in this dental office.
Dates of observation at this office:
I observed a total of _________ hours in this office.

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11/08/12 R:\Dental\DH Application\Application Form\DH Application 2013.part 1.docx 1
ROSE STATE COLLEGE
DENTAL HYGIENE PROGRAM
APPLICATION PROCEDURE
FALL 2013 Entry
CLASS OF 2015
The following steps must be followed before an application can be considered complete. All materials must be on file in the Dental Hygiene Program office by February 1, 2013. Applications will only be accepted if turned in by 5:00 p.m. on February 1, 2013 or postmarked February 1, 2013. Any documentation submitted after the application deadline will not be considered in the computation of candidates' points. The signature of the applicant is required in several areas of the application. The application will not be considered complete unless all documents have appropriate signatures. All application information and documentation will become part of the applicant file and will not be returned to the applicant.
1. Complete the application for admission to the Dental Hygiene Program.
2. Forward official transcripts from ALL colleges and universities attended. This is your responsibility. Copies are acceptable if Rose State College Admissions Office has official transcripts on file. However, it is the responsibility of the applicant that ALL transcripts or copies are on file with the Dental Hygiene Program. You may choose to personally deliver them to the Dental Hygiene Program office. A Rose State College advisement sheet is acceptable for completed RSC courses. Final fall semester 2012 grades must be submitted before the deadline. Any degree awarded must be posted on a transcript or verified by a copy of the diploma.
3. Complete the form indicating planned spring and summer 2013 enrollment information. If you are not enrolled in any spring 2013 course work, please indicate on the enrollment form, sign and return the form with the application. CHEM 1124, Introductory Organic/Biochemistry should be completed by the end of spring semester 2013.
4. ACT scores are required. Submit ACT Scores. It is permissible to have retaken the ACT examination. A copy of the RSC advisement sheet is acceptable documentation if the current scores are listed. Residual scores are accepted. ACT scores must be within three (3) years or not older than spring 2010.
5. COMPASS reading, writing, and math exam scores are required for program application. These are given at Rose State College daily in Student Services building, Room 210. Please see page 3 for additional information and take this information with you when you take the examinations. You must turn in your score sheet or a copy of the results with your completed application. A RSC advisement printout is acceptable documentation. COMPASS scores from other institutions are acceptable if printout submitted includes institutional information. COMPASS scores must be within three (3) years or not older than spring 2010.
6. Employment or observation, other than as a patient, in a dental office is required. This is usually a strong deciding factor in the decision to seek a career in dental hygiene. Additional points will be added to your application depending on the length of your employment or if you spent the equivalent of one week (32-40 hours) observing in a dental office. If observation is less than 32 hours no points will be awarded. To receive this credit, complete the Dental Office Experience form on page 7. Blank form may be duplicated for verification by more than one dentist. No points or credit will be awarded unless form is signed by the dentist and the applicant, and submitted before application deadline.
11/08/12 R:\Dental\DH Application\Application Form\DH Application 2013.part 1.docx 2
7. If you have worked as a dental assistant and have current expanded duty certificates from the Oklahoma Board of Dentistry, points will be added to your application. If you are currently a Dental Assisting National Board, Certified Dental Assistant (CDA) one point will be earned. To receive credit, provide copies of the current (2012-2013) certificates. These documents must be turned in with your application.
8. Complete Application Point Worksheet and submit with application. Documents verifying worksheet entries must be submitted: transcripts; test scores; diploma or certificate verification.
9. If you have made application to the Dental Hygiene Program within three years, please indicate on application. Any application materials you wish to transfer from a previous application can be transferred to your current application if requested in writing. We must have a new application for admission and current transcripts reflecting recent coursework. It is the responsibility of the applicant to provide all updated requested materials for the current application period.
10. Letters indicating your application status will be sent to you at the address on your application. You should receive this letter during the first week in March. Instructions for scheduling an interview will be stated in the letter. All interviews will be scheduled in March.
11. All steps outlined above must be completed and all material submitted to the Dental Hygiene Program office by 5:00 p.m. on February 1, 2013. Personal interviews are one of the final steps in the application procedure.
Send ALL materials to: Dental Hygiene Program
Rose State College
6420 Southeast 15th
Midwest City, Oklahoma 73110
Telephone: (405) 733-7337
ADDITIONAL INFORMATION:
Failure to designate Dental Hygiene Program as a part of the address on the envelope may result in delay or loss of your material. It is the applicant’s responsibility to see that their application folder is complete. All application information and documentation will become part of the applicant file and will not be returned to the applicant.
The highest ACT composite score, course grade, and COMPASS scores will be utilized in the evaluation of the Dental Hygiene Program applicant. Letters of recommendation are not required for application to the Rose State College Dental Hygiene Program. If letters are submitted they are not utilized in the selection process.
The opportunity to interview is based on criteria and points earned including required course GPA, ACT composite score, COMPASS scores, number of required science courses completed, experience and education achievements. Education achievements include degrees posted on transcripts, current DANB certificates, and current Oklahoma Board of Dentistry certificates. Interview invitations and class selection are based on total points earned.
The signature of the applicant is required in several areas of the application. The application will not be considered complete unless all documents have appropriate signatures.
11/08/12 R:\Dental\DH Application\Application Form\DH Application 2013.part 1.docx 3
COMPASS TEST
TESTING REFERRALS
You must see a counselor in Student Development, SSB, Room 100 for a testing slip.
TESTING POLICY
You may test twice during each enrollment period. The first day of Spring Enrollment in November begins one enrollment period and the Summer/Fall combined enrollment period in April begins the second enrollment period.
TIPS FOR TAKING THE TEST
 Be well rested before you test. If you are hungry, eat something before you test.
 If you have children with you, return when you have a sitter.
 If you wear glasses or contacts, be sure to have them with you.
 Try and relax (take a deep breath).
 Read the directions carefully. This is very important.
 Make use of the practice items provided by COMPASS. See the RSC website information below.
 Although the test is not timed, give yourself at least an hour and a half (preferably two hours) to complete the entire battery of tests before the Testing Center closes.
 Do your best. The test scores will be used for Dental Hygiene Program admission.
TESTING HOURS
Monday - Tuesday 8:00 am - 8:00 pm
Wednesday – Thursday 8:00 am - 6:00 pm
Friday 8:00 am - 5:00 pm
READING TEST TIPS
 After you answer all questions about a passage, you will be able to change your answers. You must answer all the questions about a passage before you can go back and make changes.
 Each test has a built-in practice session to familiarize you with the kinds of questions that you will encounter.
WRITING TEST-ESSAY TIPS
 Remember that while you are correcting an essay, you can change any part of the essay as many times as you like. Be sure all necessary corrections have been made before clicking “go on”.
MATH TEST TIPS
 Use of non-graphing calculators is allowed. You will also be able to use scratch paper and pencil. You will obtain these materials from the testing personnel.
 You will not be allowed to return to previous questions in order to change your answers. You must answer each question presented to you. You will not be penalized for guessing.
REMEMBER, you can always get extra help by pressing the “Help” key.
* Study guides for the COMPASS test are available at Student Services or the Testing Center. Rose State College COMPASS prep web page is located at http://www.rose.edu/compass-test-study-guide. Follow the links to the individual test study guides. 11/13/12 R:\Dental\DH Application\Application Form\DH Application 2013.part 2.docx 1
ROSE STATE COLLEGE
HEALTH SCIENCES DIVISION
6420 S. E. 15TH STREET
MIDWEST CITY, OKLAHOMA 73110
(405) 733-7359
APPLICATION FOR ADMISSION TO:
Dental Assisting: Nursing Science:
Certificate Beginning Track
Associate Program Career Ladder Track
Dental Hygiene Phlebotomy
Clinical Laboratory Technology Radiologic Technology
Health Information Technology Respiratory Therapist
Health Information Coding Specialist Certificate
NAME
(last) (first) (middle) (maiden)
RSC STUDENT I.D. # and /SOCIAL SECURITY #
EMAIL ADDRESS
HOME PHONE CELL PHONE #
ADDRESS
(number & street) (city) (state) (zip)
PERMANENT ADDRESS
(number & street) (city) (state) (zip)
EMPLOYER WORK #_______________JOB TITLE:
ADDRESS
(number & street) (city) (state) (zip)
PERSON TO CONTACT IF WE ARE UNABLE TO REACH YOU OR IN CASE OF EMERGENCY NOTIFY:
NAME PHONE
ADDRESS:
(number & street) (city) (state) (zip)
RELATIONSHIP:
HOW DID YOU LEARN OF THE ROSE STATE COLLEGE DENTAL HYGIENE PROGRAM?
SOURCE: INDIVIDUAL’S NAME: 11/13/12 R:\Dental\DH Application\Application Form\DH Application 2013.part 2.docx 2
Have you applied to the Rose State College Dental Hygiene Program before? (yes) (no)
If so, year year year
HIGH SCHOOL GRADUATE OR GED
(last high school attended) (year) (year)
(city) (state)
Have you participated in the ACT (yes) (no); if so, year year year
List all colleges or universities attended since leaving high school. All college transcripts must be on file in the Dental Hygiene Program office by the deadline.
NAME OF INSTITUTION CITY/STATE ATTENDANCE DATES MONTH/YEAR CREDIT HOURS EARNED DEGREES AWARDED
N O T I C E
NOTIFY THE PROGRAM DIRECTOR SHOULD ANY OF THE FOLLOWING SITUATIONS RELATE TO YOU:
> CONVICTED OF A FELONY OR HAVE FELONY CHARGES PENDING;
> COURT COMMITTED FOR MENTAL INCOMPETENCY;
> HABITUALLY INDULGED IN OR ADDICTED TO DRUGS OR ALCOHOL; OR
> CONVICTED OF FELONY OR ILLEGAL PRACTICE OF DENTISTRY.
THESE CONDITIONS MAY AFFECT YOUR ELIGIBILITY FOR LICENSURE, REGISTRY OR CERTIFICATION CREDENTIALS AND CONSEQUENTLY MAY HAVE A BEARING ON EMPLOYABILITY. ALL INFORMATION WILL BE HELD CONFIDENTIAL.
I affirm that the information, which I have provided for this application, is complete and accurate. I understand that my application will not be considered unless all necessary official transcripts have been submitted by the deadline and the application procedures completed.
SIGNATURE DATE 11/13/12 R:\Dental\DH Application\Application Form\DH Application 2013.part 2.docx 3
Spring 2013
I am enrolled in the following classes for the spring semester:
Course # Credit Hours Course Name College
Summer 2013
I plan to enroll in the following classes for the summer semester:
Course # Credit Hours Course Name College
I am not enrolled in any courses for the spring semester, 2013.
I do not plan to enroll in any courses for the summer semester, 2013.
Applicant's Signature Date
SPRING/SUMMER 2013 ENROLLMENT 11/13/12 R:\Dental\DH Application\Application Form\DH Application 2013.part 2.docx 4
The following minimal physical and mental qualifications are necessary to be considered for admission into and progression through the Rose State College Dental Hygiene Program:
1. The ability to move around in patient operatory area, laboratory and other work areas.
2. Visual acuity sufficient to observe and assess patient behavior, instrument and assess intra and extra orally,
and accurately operate equipment.
3. Auditory acuity sufficient to hear instructions, requests, and monitor equipment.
4. The motor ability necessary to manipulate instruments and equipment and to utilize palpation in patient
assessment.
5. The ability to speak, write, comprehend, and communicate the English language proficiently.
6. The ability to communicate in a professional manner and establish rapport with patients, peers, colleagues, and Program staff and personnel.
7. The ability to think critically and use problem-solving skills.
8. The ability to resolve conflicts appropriately and function effectively in stressful situations.
Rose State College will provide reasonable accommodations to persons with disabilities in order for students to have access to educational programs and services. Students with disabilities requiring accommodations should make the initial request for accommodation to the Counselor for Students with Disabilities. See Rose State College Student Handbook for further details.
STATEMENT OF ACKNOWLEDGMENT
I understand that I must be able to meet the above physical and mental qualifications independently or with reasonable accommodation. I understand that I am responsible for communicating requests for accommodation to the Counselor for Students with Disabilities.
I affirm that the application information, which I have provided in this application, is complete and accurate. In addition I affirm that the Experience/Observation form in accurate and is a truthful statement of my experience and/or observation. I understand that my application will not be considered unless all necessary documentation has been submitted and the application procedures completed by the published deadline. In addition, I understand that all applications and documentation will become part of the applicant file and will not be returned to me as the applicant.
SIGNATURE DATE
PHYSICAL AND MENTAL QUALIFICATIONS 11/13/12 R:\Dental\DH Application\Application Form\DH Application 2013.part 2.docx 5
DENTAL HYGIENE APPLICATION ACADEMIC WORKSHEET
ROSE STATE COLLEGE
FALL 2013 Entry
CLASS OF 2015
APPLICANT NAME_____________________ __SID# DATE____________
Complete worksheet and enter only information requested in blank spaces and submit with application.
Verification of this worksheet will be completed by Dental Hygiene Program personnel.
I. GRADE POINT AVERAGE GENERAL EDUCATION (25 POINTS POSSIBLE)
COURSE
COURSE # and NAME
GRADE
SEM & YEAR
COLLEGE
English Comp I
English Comp II
Speech
U.S. History
Amer Fed. Govt.
Intro Sociology
Intro Psychology
Nurtrition
Grade Value GPA Point Range
A=4 3.7- 4.00= 25
B=3 3.5-3.69 = 20
C=2 3.0-3.49 = 15
D or F =0 2.5-2.99 = 10
2.0-2.49 = 5
II. GRADE POINT AVERAGE SCIENCE EDUCATION (20 POINTS POSSIBLE)
COURSE # and NAME
GRADE
SEM & YEAR
COLLEGE
Intro Chemistry
Intro Bio/Org Chem
Microbiology
Human Anatomy
Human Phys.
Grade Value GPA Point Range
A=4 3.7-4.00 = 20
B=3 3.5-3.69 = 17
C=2 3.0-3.49 = 15
D or F =0 2.5-2.99 = 10
2.0-2.49 = 5
III. REQUIRED SCIENCE COURSES COMPLETED (5 POINTS POSSIBLE)
Check those completed with a grade of “C” or better. One point is awarded for each course completed.
Introductory Chemistry yes no
Intro Org/Bio Chem yes no
Microbiology yes no
Human Anatomy yes no
Human Physiology yes no 11/13/12 R:\Dental\DH Application\Application Form\DH Application 2013.part 2.docx 6
IV. ACT COMPOSITE SCORE (15 POINTS POSSIBLE)
Score_______ Year_______ Location
Point Range
33-36=15 points
30-32=13 points
27-29=11 points
24-26= 9 points
21-23= 7 points
19-20= 5 points
16-18= 3 points
0-15= 0 points
V. COMPASS SCORES (15 POINTS POSSIBLE)
Writing Skills Score
Scores Points
0 - 75 0 Date
76-80 1
81-85 2
86-90 3
91-95 4
96-100 5
Pre-Algebra/Numerical Skills Score
Scores Points
0-60 0 Date
61-70 2
71-80 3
81-90 4
91-100 5
Reading Score
Scores Points
0-80 0 Date
81-84 1
85-88 2
89-92 3
93-96 4
97-100 5
VI. EDUCATIONAL EXPERIENCES (8 POINTS POSSIBLE)
Higher Education Degrees Received (2 to 3 points):
Type of Degree Subject Date College
Total college credit hours earned:
Board of Dentistry Dental Assisting
Certificates:
 Radiation Safety (1 point) Yes_____ No _____
 Assisting with Nitrous Oxide (1 point) Yes_____ No _____
 Coronal Polishing/Fluoride Application (1 point) Yes_____ No _____
 Pit and Fissure Sealant Placement (1 point) Yes_____ No _____
Dental Assisting National Board Credential, CDA (1 point): Yes_____ No _____ 11/13/12 R:\Dental\DH Application\Application Form\DH Application 2013.part 2.docx 7
VII. MISCELLANEOUS INFORMATION
I have previously applied to the Dental Hygiene Program: Yes_____ No_____
If yes, what year(s) __________, ___________, _________.
I have attended a Dental Hygiene Program Information Session:
Yes_____ No_____
I have attended a Dental Hygiene Program Applicant Workshop:
Yes _____No_____
I have worked as a chairside dental assistant:
Full time: Yes_____ No_____
More than one year
Less than one year
OR
Part time: Yes_____ No_____
More than one year
Less than one year
I have worked the front office in a dental office:
Full time: Yes_____ No_____
More than one year
Less than one year
OR
Part time: Yes _____ No_____
More than one year
Less than one year
I have observed in a dental office or dental offices
32+ hours less than 32 hours
NA due to work experience
I affirm that the information on the Applicant Worksheet is accurate and complete to the best of my ability.
________________________________ _________________________
Signature Date ROSE STATE COLLEGE DENTAL HYGIENE PROGRAM
Dental Office Experience/Observation Form
Instruction to applicant: Attach this completed form to your Dental Hygiene Program application and submit by application deadline, February 1, 2013. Copies of this form may be made to list additional offices. TO BE COMPLETED BY THE APPLICANT:
Applicant’s Name: SID #
Dentist: Dental Office Name:
Address:
Street City Zip Code
Dental Hygienist:
Check One:
Type of Practice: General OR Specialty (identify)
I was employed by: OR I observed:
Dentist: Dentist:
Dental Hygienist:
Applicant Signature Date TO BE COMPLETED BY THE DENTIST:
I certify that the applicant named above worked or observed in this office for the period of time stated. While in the office, he/she was exposed to the role of each member of the office dental health team.
Validation Signature:
Dentist Date
Form must be signed by the DENTIST for credit to be awarded.
EMPLOYMENT
Check One:
OR OBSERVATION
I was employed part time in this dental office
I was employed full time in this dental office
I am employed part time in this dental office
I am employed full time in this dental office
Dates (months and years) of employment at this office:
My primary responsibilities:
(Check those that apply)
Front Office
DDS Chairside Assisting
RDH Chairside Assisting
Other (specify):
I observed in this dental office.
Dates of observation at this office:
I observed a total of _________ hours in this office.